1. The AMA’s Report and Guidelines
In June 2007, the American Medical Association (“AMA”) released a report entitled “Medical Travel Outside the U.S.,” that tried to explain why people are going abroad for medical care. According to the AMA, the primary reasons that Americans are traveling for treatment are the ever escalating-cost of healthcare and the lack of affordable health insurance.
On June 16, 2008 the AMA re-entered the conversation with Guidelines on Medical Tourism. These guidelines address important issues of patient safety, transparency, financial incentives, after care, and legal liability. The AMA’s contributions to the medical travel industry at such an early stage is notable and important. Many American doctors strongly disapprove of patients who seek care abroad and few will agree to provide follow-up care for returning medical travelers. Those doctors are understandably concerned about incurring liability for another physician’s malpractice.
Widespread resistance in the medical community led many to believe that the AMA would either ignore or actively oppose the development of the medical travel industry. Instead, most were surprised by the AMA’s desire to get out in front of the issue and announce guidelines that some view as a traveling patient’s bill or rights.
As the health insurance industry and employers begin to explore the cost savings and benefits of medical travel, the AMA’s contributions promote patient safety and protection. The AMA has legitimized a nascent industry with only limited support from mainstream healthcare networks. Since the AMA entered the discourse, more and more health insurers are evaluating whether medical travel makes sense today, tomorrow or sometime soon.
At this stage, AMA does not seem intent to stamp out medical travel. This may be due in part to the movement’s consumer-driven nature and the reality of restricted resources at home. Instead, the organization of medical professionals will propose model legislation to all states that protects patients who go abroad for treatment.
2. The Guidelines and Who Will be Impacted
The AMA’s Guidelines on Medical Tourism are enumerated below. Each addresses important components of patient decision-making, safety, protection and recovery.
a. Medical care outside of the U.S. must be voluntary.
b. Financial incentives to travel outside the U.S. for medical care should not inappropriately limit the diagnostic and therapeutic alternatives that are offered to patients, or restrict treatment or referral options.
c. Patients should only be referred for medical care to institutions that have been accredited by recognized international accrediting bodies (e.g., the Joint Commission International or the International Society for Quality in Health Care).
d. Prior to travel, local follow-up care should be coordinated and financing should be arranged to ensure continuity of care when patients return from medical care outside the US.
e. Coverage for travel outside the U.S. for medical care must include the costs of necessary follow-up care upon return to the U.S.
f. Patients should be informed of their rights and legal recourse prior to agreeing to travel outside the U.S. for medical care.
g. Access to physician licensing and outcome data, as well as facility accreditation and outcomes data, should be arranged for patients seeking medical care outside the U.S.
h. The transfer of patient medical records to and from facilities outside the U.S. should be consistent with HIPAA guidelines.
i. Patients choosing to travel outside the U.S. for medical care should be provided with information about the potential risks of combining surgical procedures with long flights and vacation activities.
Generally, these guidelines appear to be directed to health insurers and employers incorporating foreign providers into healthcare plans and to a lesser extent medical travel experts coordinating the patient travel experience. The Guidelines seek to protect patients from being pressured by healthcare payers to accept lower quality care without recourse in the event of a bad outcome. The AMA repeatedly stresses the importance of informing patients of their rights and recourse, the hospital and doctor’s credentials, and potential risks associated with combining travel activities with surgical procedures.
3. Implementing Key Guidelines
a. Patient Safety
The majority of the AMA’s Guidelines are aimed and ensuring patient safety. The Guidelines call for treatment abroad to be voluntary and for financial incentives to not restrict treatment options. This measure is meant to avoid patient coercion and withholding important information about available alternatives. The AMA also requires that institutions treating patients be accredited by recognized international accreditation bodies. This rule tries to ensure that patients are treated in safe and clean facilities that meet international standards of patient care, infection control and hygiene. The AMA also requires that patients be informed of the risks of combining surgical procedures with travel activities. The Guideline’s proscription against transferring patient medical records in violation of HIPAA aims to reassure patients that their privacy rights will continue to be safeguarded abroad.
Through various tools, each of these standards seeks to protect patients from potential dangers associated with traveling abroad for care, especially when the patient is sent by an insurer with an incentive to reduce costs. Notably, while setting out these basic patient safeguards, the AMA did not establish any serious roadblocks to further industry development.
Insurers are likely the best suited to implement the patient safety standards. Health insurers can move large numbers of patients toward or away from specific providers. Their economic clout gives insurers to ability to demand that providers and medical travel professionals adhere to relevant patient safety standards. Insurers are also best situated to make sure that patients only travel voluntarily and are not offered financial incentives that restrict their treatment options.
The AMA’s Guidelines also require that post-surgical follow-up care be organized and pre-paid for patients returning from treatment abroad to ensure continuity of care. Continuity of care is one of the most significant institutional hurdles to the industry’s development. The AMA hit the nail on the head. American doctors worry that by treating returned patients they may expose themselves to liability for another doctor’s malpractice.
It is incumbent upon the AMA’s membership and healthcare insurers to collaborate to implement follow-up care standards. American doctors must participate if returning patients are to receive follow-up care at home. To do so, the industry must address the doctor’s legal liability concerns. One suggestion is for insurers to require participating physicians to treat medical tourists as a condition of being in the network. Such a strong-arm approach likely won’t sit well with physicians who are counting their own bottom line, including malpractice insurance premiums.
c. Legal Liability
By highlighting the need for patients to understand their rights and legal recourse to enforce those rights, the AMA touched on the other key issue stymieing the medical travel industry. Lawyers of various disciplines have come together to address how to limit potential liability exposure in the event of a bad patient outcome. Insurers are keen to solve this problem before launching full-fledged programs sending patients abroad.
Patients should be advised that their legal right to sue a doctor or hospital for malpractice depends on the legal system of the country they have selected for treatment. It is unlikely that patients can sue a foreign provider in the U.S. due to lack of jurisdiction over the foreign entity. Generally, health plans can only be sued for negligent claims administration, not for the provider’s negligent care. In the case of malpractice, the patient may only be able to sue the foreign provider where the treatment occurred. It is unclear whether courts will try to step in to provide injured medical travelers some recourse in the US, and if so, who will be left holding the bag. As cases are decided, more guidance will become available and be passed on to patients.
Finally, the Guidelines call for patients to have access to facility accreditation, physician licensing and outcomes. Full disclosure of licensing, accreditation and outcomes data is important for patients considering treatment abroad. Patients should have complete information to compare providers. The problem is that outcomes data is rarely available from US providers. This standard places a greater burden on foreign providers than is on domestic providers to demonstrate their performance record.
To implement the AMA’s transparency standard, medical tourism professionals and insurers should work with foreign providers to accumulate responsive data and then make the data accessible to patients. Current industry projects aimed at providing an even greater level of transparency are underway. The participants understand that this is an expensive and long-term project that will require cooperation from everyone. Today, licensing and accreditation data is readily available from all providers serving American patients. Outcomes data and other quality of care indicators are less universal but may be readily available within the next five years.
Both patients and the medical travel industry are well served by the AMA’s Guidelines for operating in this new frontier. The AMA fills an important role in this discussion, both advocating for patient’s rights and protecting the interests of the medical community. Every industry constituent should be aware of and implement the AMA’s Guidelines. While certain standards, like providing patients with information about foreign providers, are already customary, others, such as follow-up care for returning patients, will take time and dedication to be fully realized. Through continued participation in the industry, the AMA can help to implement the Guidelines that require the participation of its membership.